A Psychiatrist in Gorazde

Monday. Something has happened in Gorazde. I have the feeling I am on the receiving end of an exponential increase in violence and distress, as if my being a psychiatrist here has suddenly given people permission to go mad. This morning, instead of preparing my seminar, I had to see a young woman who had stopped me in the hospital courtyard two days ago saying she was having a nervous breakdown. The story is a simple one: Elvira is 18 and she and her husband are refugees from a village near Visegrad (now in Republika Srpska). They share two rooms – a bedroom and living-room/kitchen – with his sister and her husband. The latter couple sleep in the kitchen, but the two women were fighting all the time, so Elvira decided to set up separate cooking facilities in the bedroom. This led to an almighty family row, with her husband threatening to leave, and Elvira running out and jumping into the Drina. As she sits there with dark shadows under her eyes, wringing her hands, saying she hadn’t wanted to die but did not know what to do, I suddenly recognise her. Back in Britain, I had been seeing her counterpart on the emergency wards at least once a week for two years: there’d been a row with parents or boyfriend the night before and she’d reached for a bottle of paracetamol as one clear way of communicating intolerable distress. Here the river is more accessible, and while I can reassure the girl that she is not going mad, and that getting the family together to talk about the conflict might provide a more lasting solution than the injections of diazepam she has been getting from the emergency room, I cannot provide new accommodation or any possibility of a return home.

In the afternoon two social workers interrupted a crucial seminar on the use and abuse of minor tranquillisers, to ask if I could come and see another 18-year-old who had been holding her family at bay with a shotgun, and threatening to kill herself. When, after some hours, the police had disarmed her, she had bitten them and become highly disturbed. At the police station, I find a dishevelled and exhausted young woman sitting quite quietly with a woman police officer. We talk and she tells me of her best friend’s suicide in front of her a year ago, also with a shotgun, which she replays and replays in her mind, of her guilt at not stopping it and her feelings of hopelessness. She is certain that she will try to kill herself again if given a chance. My immediate choice is between admission to the intensive care ward in Sarajevo or to a police cell. The police tell me the cells are full and the hospital social worker tells me it is too late for a car to take the ‘blue route’ through Republika Srpska, which means using the ‘Corridor’ over Grebac mountain, but as yet the hospital ambulance is not back from a journey to Sarajevo. Dr A. in the emergency room says it’s not her problem. If the girl shoots her family and herself, it certainly will be, I shout. The trouble with shouting through my translator, Dzibrila, is that she gets the flak from me, and Dr A. just gets Dzibrila’s careful moderate tones. Never mind: I got my ambulance and a nurse escort. Luckily, the girl actually wanted admission and accepted an injection of chlorpromazine. She’s quite small so if she gets agitated in the car two adults can contain her. I cannot raise anyone at the Kosevo hospital in Sarajevo on the phone, so I write a long letter and pray they will accept her.

Before I came out here, I thought the ‘Corridor’ promised by the Dayton Peace Plan was a decent highway, like the road to West Berlin, linking the former enclave of Gorazde safely to the Bosnian Croat Federation without going through RS. The reality is four parallel lines on a map and a single track road that is benignly named ‘Canary’ on the IFOR maps and on little white placards beside the road. The name doesn’t seem particularly appropriate for a route that is in large part a dirt track and that switchbacks across mountains taking four hours to drive in the winter. There is a bus twice a day that goes through RS and takes only two hours, but when Dzibrila was on it a few weeks ago, it was stoned by four youths outside Rogatica, glass shattering by her head. Cars with Gorazde number plates are often stopped by Serb police who offer the driver the choice between an instant fine and a court appearance. UNHCR has argued that there should be a uniform number plate for the whole country so that it is impossible to identify a driver’s origin, but there is no sign of this being implemented.

Tuesday. A calmer day. I spent an hour with Bojan, who first came to see me because he was worried about the drugs he was taking. At that meeting he had talked without interruption for almost an hour, telling me about his friend killed in the war and about the week when he thought he was having a heart attack and was going to die, as did the local doctors who kept him on chest monitors and sent him off to Sarajevo, where they told him that ‘it was in his mind’ and put him on benzodiazepines. A year later he is still on them, feeling OK if he takes them and fine for the first few days after he stops, then back come the chest pains and the singing in his ears and dizziness, and the shortness of breath, and the fuzzy vision. I go over the physiology of anxiety and the effects of benzodiazepine withdrawal. On one level he understands and it makes sense. Indeed, he is absolutely determined to stop taking the drugs, angry that he should have been given them and reducing them at a faster rate than I advise. On another level he is still terrified that he is going to die of a heart attack, angry with the doctors for ‘implanting’ this fear and furious with everyone for the way things are. This week he says he cannot see what it was all for: ‘My Serb neighbours will come back and I will have to “forgive” them, so what was the point?’

The town is drowning in a sea of tranquillisers. Almost everyone I have seen is taking benzodiazepines as a matter of course, obtained either from a doctor or a friend. One soldier told me that at the height of the fighting he was taking 60 mg of diazepam a day. The aid agencies delivered them in large quantities during the war and now we are stuck with all the problems of dependence.

I run back for lunch at Médecins sans Frontières, then back to the ‘counselling flat’. This is the small rented apartment I use for seminars, group and family work, and individual work with children. Once a week, four GPs come from the hospital for a two-hour seminar in psychological medicine. Given their workload I am both touched and impressed by their persistent interest, but they know that unless the Ministry of Health pulls its finger out, when MSF leaves there will once again be no psychiatrist in Gorazde. The town did have a psychiatrist once. He left for Austria with his two children at the beginning of the war and wants to stay there until they complete their education. There is an excess of psychiatrists in Sarajevo, but none of them wants to move here. Part of this is metropolitan snobbishness; mostly it is uncertainty about the future of the town.

At 5 p.m. I run to an inter-agency meeting. There are 14 NGOs working in this town and the United Nations High Commission for Refugees gets them together on a weekly basis, along with other military and civilian personnel. I am beginning, after four months, to get functions and acronyms straight. There are the Portuguese and French SFOR (the Stabilisation Force), driving around the place in armoured personnel carriers and tanks, to make sure that compliance with the military aspects of Dayton continues. There is LANDCENT, a multinational bunch of soldiers, who are extremely friendly, make excellent tea and whose function remains a mystery. Then there is the Office of Security and Co-operation (OSCE), dealing with human rights and preparing for local elections. There are also European Community monitors, all dressed in white, like a Persil advert; the IPTF (International Police Task Force), which keeps us informed as to the number of stonings, beatings and other crimes and misdemeanours occurring in the locality; and UN Civil Affairs, which briefs us on local and national events.

This meeting is to keep us up to date on political and security issues and enable us to co-ordinate our activities. Remarkably, it does all these things effectively and with good humour. The discussion is dominated by concerns about freedom of movement. A few weeks ago the bus to Sarajevo was held up and the passengers robbed; a car using the Corridor was shot at. NGO vehicles are not immune: one of the expats has had a gun waved at him because he would not accelerate in the snow. So feelings of isolation and vulnerability grow. Everything is affected. People cannot market goods when it costs so much to rent a truck one way to Sarajevo. They are scared to send their children on school trips or sports events, to attend hospital appointments, or visit the family. IPTF argue that their job is to ‘monitor’ not escort, as escorting would imply intervention if necessary. SFOR say that it is not part of their mandate to protect civilian traffic. This is in spite of the fact that the Dayton Agreement specifically states the contrary. No one knows if and when the Dayton promise to build a secure route will be fulfilled.

Wednesday. Word seems to have got round among the Bosnian Army soldiers that I am OK. Another new one came today, with a painful story of beating and imprisonment. He has already given testimony at The Hague and the story had a slightly rehearsed feel about it. Repeated telling is clearly not enough, however, as he is self-medicating with large quantities of alcohol and drugs, and wants help in stopping. Before I arrived I was worried that working through an interpreter would be too inhibiting, but my patients tell me they don’t mind. Indeed, they prefer the fact that I am an outsider, saying that they could not talk this way to someone local. In the afternoon 11 children come for a bereavement group, which I run with Amra, the local paediatric nurse. Every one of the children has lost at least one parent during the war. At the assessment interviews it was the remaining parents who burst into tears: the children were calm, serious and attentive. Gorza, our tireless hospital social worker, runs a parallel informal parents’ group. The children seem to love their group, perhaps because it is their only chance to talk like this. Last week we discussed change and loss. Today each child told us exactly who had died, and as we went round the room listening to each solemn declaration – my father was shot on the front line, my mother was hit by a grenade in the bathroom, my father was hit by snipers in the street – it was Amra and I who were crying.

Thursday. I am beginning to understand a little more about the expression of grief in this society. One of my patients today was a middle-aged man who lost his 12-year-old daughter three years ago: she was hit by a grenade when playing outside. He has never cried. He believes it would be wrong to do so, as parents crying over children fill the grave with tears, and prevent the child being happy in paradise. Like so many I see, he has terrible chest pain. ‘This is not an imaginary pain,’ I tell him, ‘your heart aches with grief.’ This makes sense to him, but he still prefers not to talk about it and I do not necessarily think that the insistence on the expression of emotion, beloved by Western psychiatrists, will be healing if it goes against the grain of what he believes to be right. I wonder if any one of us knows what is right in this particular situation. The rituals of mourning are designed for the singular loss, when others are around to offer acknowledgment and support, and play whatever role is right for a bystander. Here, no one is a bystander, everyone is suffering, and perhaps the rituals cannot contain the feelings generated. I told this particular patient, who is a deeply religious man, that I was not quite sure what to advise, but that I thought three years was perhaps too long to be in this kind of pain and that I myself would like to know what the hodja suggested.

A small girl and a tired mother turn up. The small girl wets her bed and the mother never feels well. Both are refugees from Kopaci, the Serb suburb of Gorazde that is now in RS. They can see their old home from the main road when they pass on the bus and they would like to go back. Under Dayton they have that right, and as Kopaci is in the ‘zone of separation’ the local authorities should be facilitating the ‘phased and orderly returns’ agreed with UNHCR. Indeed, the local president of Kopaci Executive Council, Mr Topalovic, told me some months ago that he wanted ‘Serb Gorazde’, as he calls it, to be a ‘zone of ethical, human and religious tolerance’. At the same time there could be no possibility of Muslim refugees returning there while Serb refugees had no place to live, and I should understand that Serb refugees had ‘no interest in going to another entity’. When Serb refugees get the chance to speak for themselves without fear, however, this is not always the case. Last week the OSCE and UNHCR arranged a visit by Serb villagers to their homes in a nearby village on the Bosnian Federation side, where they were welcomed without problems and guaranteed security by the local Bosnian police. Indeed one Serb man told the Muslim family occupying his home that they could stay on downstairs, while he moved in upstairs. Unfortunately, returns are not so easy in the other direction. Mines have been planted and houses blown up to prevent them. And some members of the RS Cabinet have made it clear that they ‘cannot allow any integration trends in Bosnia’. My patients continue to live seven, eight or nine to a room, in squalid collection centres and borrowed flats – not the easiest environment in which to practise good parenting.

Monday. Another emergency, another angry soldier. Semir is tall, thin, flushed and articulate. Words pour out: he believes the retreat from the Serb offensive in 1994 was mishandled by the Bosnian Army and that was why his best friend died; he fantasises about blowing up the café where ‘those responsible’ drink. I hear similar stories from others. With Nedjad it is fury at the local police, who, he feels, had a cushy war while he was on the front line, and now they have jobs and swagger around in their uniforms. There is one in particular he would like to kill: indeed he had his shotgun with him the other night and thought of using it.

This is my other problem – how to assess dangerousness. If one used British criteria, one would worry about most of the young male population of this town. They are angry, resentful, irritable and on drugs of various kinds; most have access to dangerous weapons and have spent the last four years having to kill people in order to survive. Luckily, they do not all come to see me, but I have to make decisions about the ones that do. I have already sent one obviously psychotic young man to Sarajevo in handcuffs. Nedjad is not psychotic, and I hope that ventilating his feelings once a week, and promising to leave his gun at home in the evenings, is enough for now. Semir, on the other hand, is very ill: besides his anger with his own side, he has developed paranoid ideas about his wife, suspecting her of creeping out every night to have an affair. He imagines noises and hallucinates faces in the house. He knows he is sick, however, and wants to take medication; his wife is supportive and understanding and neither wants him to go to hospital. I have sedated him with large amounts of anti-psychotic drugs, which I pray will help to change his thinking and give us a chance to talk at a more ordinary pace.

What comes across from all these young men is a feeling of waste, betrayal and hopelessness. They feel that nothing is finished, that this is neither peace nor war and that there is no point in trying to restart their lives, as who knows when war might start again. Anyway, there is 90 per cent unemployment in this town, so where do you find work? And how do you leave? For where? If you leave, what were you fighting for? So they hang out in the local bars drinking brandy and exchanging prescriptions and rumours, like the Nostradamus prediction circulating at the time of Hale-Bopp to the effect that the world would end when a comet hit – two men stopped me in the street one night to tell me how worried they were about this. There are more realistic rumours too: for example, that there will be a definitive partition, in which case Gorazde may be abandoned as part of some deal with RS, and a neat redrawing of boundaries. Or they wonder if Gorazde will be the launching point for a new offensive. I feel as isolated from the political mainstream as the rest of the population and no longer in any position to judge what is plausible and what isn’t. So I listen, and feel quite unable to offer those things that would be really healing: some feeling of security, some sense of a future, some idea that justice has been done.

Friday. Semir has improved: the ideas about his wife and the hallucinations have almost disappeared. Mrs C. came in with her niece this morning and kissed me on the cheek! She is an elderly lady whom I first saw three months ago, one of the old and vulnerable whom the war has tipped back into illness. From what I could piece together she had had a manic episode ten years ago followed by a bout of depression. On her first visit to me she was not interested in giving a history, sitting there in her headscarf and cardigan, waving her arm at me in the peculiar gesture older women have here – a cross between beckoning someone to come close and throwing a lasso – and saying repeatedly: ‘I can’t sleep, I can’t eat, please give me some medicine.’ I told her that in England patients complain that doctors are too brief and do not listen, and that it was a first for me to be told I was taking too long. This produced a half-smile, and her niece persuaded her to be patient and answer my questions. Eventually it became clear that she became manic again last autumn when there was news that her son might have been found. He has been missing for four years, since going to the city for food, falling asleep on the journey and getting captured by the Serbs. The hopes of his return proved false and she became ill and was hospitalised in Sarajevo. They put her on anti-psychotic medication, but she got very depressed and also seemed to be suffering from the restlessness that such drugs can cause. So I stopped them and started her on antidepressants. The restlessness has gone, she is now eating, sleeping, and working round the house again. She is very pleased with me, although still not interested in talking.

What does ‘war trauma’ mean in this context? The disruption of families and perhaps also the destruction of services. The World Bank is building 31 Community-Based Rehabilitation Centres for victims of the conflict all around the country. Gorazde will have one and it looks very impressive on paper, although no provision has been made for salaries, so it remains unclear who will staff it. The single intervention that would have the biggest impact on mental health would be implementation of the civilian aspects of the Dayton Agreement: freedom of movement would not only mean that I could get my patients to hospital in safety and that the staff necessary for a decent community mental health service could move to Gorazde, but it would also jump-start the town’s economy and enable a return to normal life. Instead of fighting over kitchen space people would be able to rebuild their homes. The fact of the matter is that Gorazde is under a social and economic siege almost as effective as the previous military siege.

Seka, our programme officer, who has lived here throughout the four-year siege, calls Gorazde and its surrounding pocket of land ‘the appendix’. It is exactly the right shape, has only a vestigial significance for the body politic, and is easy to cut off if it gets inflamed. Yet on clear days the Drina turns its own peculiar vivid blue. You can walk across the pedestrian bridge in the centre of the town as children in over-large anoraks with nylon rucksacks run past you on their way to school. There are freshly painted buildings and young people sitting on café terraces. There are men fishing and an old woman with goats on the river-bank. It is easy to understand why local people still believe this is a town worth saving.